Abstract
IMPORTANCE: With the rapid global uptake of glucagon-like peptide-1 (GLP-1) receptor agonists (GLP-1RAs), scalable behavioral adjuncts are urgently needed to support lifestyle change alongside pharmacotherapy. Microsteps, small behavior change prompts, could be one route to introduce lifestyle change. OBJECTIVE: To evaluate whether digitally delivered microsteps, augmented with short video boosters, increases behavioral expectation to adopt lifestyle behaviors among adults using GLP-1 RAs. DESIGN, SETTING, AND PARTICIPANTS: This 3-arm online randomized clinical trial was conducted between June 19 and July 1, 2025, with baseline data collection, immediate postexposure, and a 2-week follow-up. Participants were English-speaking adults using GLP-1 RAs in the US, the UK, and other countries and were recruited online through Prolific Academic. Data were collected via the Stanford Medicine Qualtrics platform. INTERVENTIONS: Participants received a single exposure to either written microsteps plus a short (approximately 2-minute) storytelling video (arm A) or written microsteps plus a short didactic video (arm B) compared with a do-nothing control condition (arm C). Behavioral nudges focused on small dietary improvements, physical activity, stress management strategies, and sleep hygiene. MAIN OUTCOMES AND MEASURES: The primary outcome was behavioral expectation to adopt health nudges, immediately after exposure and 2 weeks later. The effect on the main outcome of the microsteps intervention vs the control condition was compared; the effect of the intervention with a storytelling vs didactic video was also compared. Secondary outcomes were postexposure hope and happiness, as well as changes (over 2 weeks) in 3 key self-reported diet and exercise behaviors. RESULTS: Data from 5054 adults using GLP-1 RAs (mean [SD] age, 38.8 [12.6] years; 3361 females [66.5%]) were analyzed. Of these, 3437 (68%) lived in the US and the UK and 1617 (32%) lived in other countries. Immediately after exposure to the interventions, compared with control, standardized effects in SD units across the 8 microsteps expectation outcomes ranged from 0.30 (95% CI, 0.25-0.35) to 0.72 (95% CI, 0.68-0.77) in arm A and from 0.26 (95% CI, 0.21-0.32) to 0.77 (95% CI, 0.72-0.81) in arm B, with smaller effects 2 weeks later. The storytelling video was more effective across 7 of the 8 microsteps (breathe when stressed: arm A, 0.57 [95% CI, 0.52-0.62] vs arm B, 0.50 [95% CI, 0.44-0.55] and go outside for 5 minutes: arm A, 0.53 [95% CI, 0.49-0.58] vs arm B, 0.48 [95% CI, 0.43-0.52]). Immediate increases in hope (arm A, 0.31 [95% CI, 0.27-0.34]; arm B, 0.25 [95% CI, 0.22-0.28]) and happiness (arm A, 0.26 [95% CI, 0.23-0.30]; arm B, 0.22 [95% CI, 0.19-0.25]) were observed but dissipated by 2 weeks. At follow-up, the storytelling video group also reported reduced sugar-sweetened beverage consumption compared with the control group (-0.10 [95% CI, -0.16 to -0.03]). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, a low-cost digital intervention increased expectation to adopt health behaviors among adults using GLP-1 RAs, with effects persisting for 2 weeks. These findings suggest a potential role for the written microsteps intervention plus short video boosters as adjuncts to pharmacotherapy. Longer trials are warranted to determine whether the behavioral expectations stimulated by such interventions may lead to sustained behavior change. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT06967337.